English

Abstract

Neuroleptic malignant syndrome [NMS], although rare, is a well-documented lifethreatening reaction to antipsychotic medications with mortality rate estimated as being up to 20%. NMS was traditionally attributed to potent dopamine antagonism of typical antipsychotics but cases of NMS have been reported for each of the newer atypical antipsychotics. Aripiprazole is one such atypical agent approved by FDA for treating schizophrenia in 2002 and acute bipolar mania in 2004. Aripiprazole is a dopamine D2 receptor partial agonist with partial agonist activity at 5-HT1A receptor and antagonist activity at 5-HT2A receptor. In comparison to other atypical it posses unique mechanism of action that may limit development of hypodopaminergic state, however there are case reports of aripiprazole induced NMS, akathisia, rhabdomyolysis, parkinsonism and excessive somnolence in children. To add to this literature we report a case of 50 year old woman with multiple risk factors, developed NMS with low dose of aripiprazole. INTRODUCTION: The neuroleptic malignant syndrome (NMS) is an idiopathic, life-threatening reaction to Antipsychotic medication, characterized principally by fever, muscle rigidity, altered consciousness, autonomic instability, laboratory findings such as elevated creatine phosphokinase (CPK), 1 leukocytosis, raised liver enzymes. Serious complications are possible, including renal failure, thromboembolism, respiratory failure from chest wall rigidity, aspiration pneumonia, and arrhythmia2. Different criteria’s are proposed by different researchers for diagnosis of NMS but most commonly used are DSM-IV TR,3 and Levensons,1 criteria. Treatment consists of immediate discontinuation of the antipsychotics as well as D2 blocking agents, and most commonly used pharmacologic interventions are bromocriptine, and dantrolene.4 we report a case of 50 year old lady with multiple risk factors, developed NMS with low dose of single agent, aripiprazole. CASE REPORT: Ms XY 50 yrs old lady initially presented to the hospital in November 2009 and was diagnosed to be suffering from undifferentiated schizophrenia and was treated with olanzapine 5mg/day. Later during the course of illness she exhibited depressive symptoms and fluoxetine 20 mg/day was added which was stopped after 6 months as her depressive symptoms remitted. Olanzapine was discontinued after 2 yrs of treatment as she developed Diabetes Mellitus. Later she was initiated on Trifluoperazine 15mg daily which had to be stopped within two weeks due to severe extra pyramidal symptoms [EPS]. Trihexyphenidyl, 2 mg/day was given for 4 weeks till her EPS subsided completely and tablet aripiprazole 2.5mg/day was started which was slowly increased to 5mg/day over next 4 weeks. Within 4 weeks of starting with aripiprazole she developed EPS and at times she experienced acute dystonia. Trihexyphenidyl 2 mg/day was restarted in view of this but low grade of EPS